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PC Ado > Menstrual DOs > Flashcards

Menstrual DOs Flashcards

1
Q

What history is important in the evaluation of an adolescent with dysmenorrhea?

A

o Menstrual hx: how many days? How many pads/tampons?

o Meds: taking anything for cramps? Worse over time or new onset?

o Prior STD and sexual history

o GI/GU systems history

o Musculoskeletal history

o Psychosocial history

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2
Q

When does primary dysmenorrhea occur and how can it be described?

A
  • Onset usually occurs with the first ovulatory cycle.
  • Pain is intermittent and colicky, usually begins at time of menstrual flow and may continue for approximately 3 days.
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3
Q

When should you consider secondary dysmenorrhea?

A

pain starts with the onset of menarche or after the age of 20 years.

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4
Q

What specific questions should you ask a teen about her dysmenorrhea?

A

When it began. Better or worse?

degree of pain and the amt of impairment in school and other activities.

Any previous use of therapeutic modalities and their effectiveness should be ascertained.

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5
Q

Why ask about prior STD and sexual history in evaluating dysmenorrhea?

A

helps to eliminate infection as a cause

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6
Q

Why ask about GI/GU systems in evaluating dysmenorrhea?

A

helps to eliminate GI or GU problems (e.g., cystitis, IBS) as a cause of pain

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7
Q

Why ask about musculoskeletal history in evaluating dysmenorrhea?

A

This reveals bone or joint problems including trauma or possible tumor.

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8
Q

Why ask about psychosocial history in evaluating dysmenorrhea?

A

Evaluate for stressors, substance abuse, and sexual abuse. Cigarette smoking, especially heavy smoking, has been found to be associated with dysmenorrhea (Hornsby et al., 1998).

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9
Q

Why does primary dysmenorrhea occur?

A

Action of E & P leads to increased production of PGs –> stimulated uterine activity –> experienced as cramps, etc.

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10
Q

Primary dysmenorrhea: associated symptoms

A

nausea, vomiting, diarrhea, headache, back and thigh pain, or urinary frequency

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11
Q

Differential Dx for primary dysmenorrhea

A
  • PID - always think infection first
  • SAB
  • Ectopic pregnancy -usually painless spotting, one sided; Hx funny period
  • Congenital malformation
  • Endometriosis – always have bad periods, progressively get worse over time. Tend to be older, but maybe b/c that’s when we figure it out.
  • Ovarian cyst – one sided
  • (Appendicitis, UTI)
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12
Q

Management of primary dysmenorrhea: overview

A
  1. Block the conversion of arachidonic acid to cyclic endoperoxides
  2. Block ovulation (if it’s every month)
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13
Q

How can we Block the conversion of arachidonic acid to cyclic endoperoxides in primary dysmennorrhea?

A
  • Ibuprofen (Motrin, Advil) 400 mg q 6 hours
  • Naproxen sodium (Anaprox, Aleve) 550 (440) mg at onset and then 275 (220) mg q 8-12 hours
  • Mefenamic acid (Ponstel) 500 mg at the onset and then 250 mg q 6 hours max 3 days
  • Aspirin (works but not great w/teens and may make bleed more. Ibuprofen does decrease bleeding)

start the day before if periods regular - heating pads

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14
Q

How can we Block ovulation in primary dysmennorrhea?

A
  • OCPs
  • Depo-provera
  • Would other hormonal contraceptive methods work?? Yes! As long as takes away cyclic nature of period.

May not help immediately - OCPs take a couple months. Depo may work immediately, but may have some funny bleeding at first.

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15
Q

What is dysfunctional uterine bleeding?

A
  • Abnormal uterine bleeding without a discernible organic uterine or pelvic pathologic condition
  • Diagnosis of exclusion!
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16
Q

When does DUB usually start?

A

Most common in three years following menarche

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17
Q

Most common cause of DUB?

A

anovulation

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18
Q

Explain anovulation

A
  • Immaturity of the H-P-O Axis
  • Produces a state of unopposed estrogen – keeps building
  • Results in a fragile endometrium
  • Breaks down randomly secondary to fluctuating estrogen levels and random bleeding from uncoordinated tissue breakdown – pieces randomly falling off, may be oozing b/c not appropriately clotted
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19
Q

Characteristics of DUB

A

Bleeding is

  • Acyclic
  • Painless
  • Profuse
  • Prolonged
  • >6-8 weeks btwn menses or 2 day bleed q 10-14 days

don’t have their luteal phase

20
Q

Differential Dx for DUB

A
  • OCPs/DMPA – find out if they’re on! Mom’s in room won’t tell you.
  • Complication of pregnancy
  • Hypothyroidism – slowed down
  • PCOS – hirsutism, acanthosis n, acne, +/- overweight
  • Cervicitis/PID
  • Estrogen secreting tumor
  • Trauma – e.g., waterskiing, etc.
  • Iron deficiency anemia – chicken or egg problem
  • Thrombocytopenia – decrease in fibrinogen
  • von Willebrand Disease
  • Renal Failure/Dialysis - heparin
  • Aspirin/Anticoagulant use
  • Anabolic steroids – may look like PCOS
    *
21
Q

Important components of an evaluation of DUB

A
  • History: cyclic vs acyclic
  • Physical Examination
    • VSs, pallor (anemia), Petechiae (bleeding do), ecchymosis, thyromegaly, abdominal tenderness/mass (E secreting tumor), hirsutism, acne, obesity, striae, acanthosis nigricans
  • Pelvic
    • STIs, wet prep, trauma, pregnancy,
    • CMT, tumor
22
Q

Blood tests you’d get if you suspect DUB

A
  • Pregnancy test- consider quantitative (can follow levels – w/miscarriage will go down, ectopic will increase)
  • CBC, retic count, platlets, RDW
  • TSH/T4
  • Prolactin – hx HAs, visual changes?
  • ?PTT, bleeding time, vWF:ricof, Factor VIII antigen, ristocetin – esp present w/really heavy, it’s their first or second period. Maybe seem shocky
23
Q

Mgmt of DUB

A
  1. Stop the bleeding
  2. Replenish Iron stores
  3. Prevent another DUB
24
Q

DUB: how to stop the bleeding

A
  • Medroxyprogesterone acetate (Provera) 10 mg BID for 7 days OR
  • Low-dose OCPs (35 mcg) 1 TID until bleeding stops, then 1 tab BID rest of 21 doses OR
  • Low-dose OCPs (35 mcg) 1 TID until bleeding stops, wean to 1 tab po by day 5 and finish pack OR
  • Premarin 2.5 mg po TID or 25 mg IV q 4-6 hours until bleeding stops and then 1 low-dose OCP BID x 21 doses – if has to be hospitalized.

Give them regular hormone and can have organized period

25
Q

DUB: how to replenish iron stores

A
  • Ferrous sulfate 325 mg po BID x 2-3 months with Vitamin C (absorption)
26
Q

DUB: How to prevent another DUB

A
  • Cyclic use of OCPs
  • Provera 10 mg QD every 35 days x 7 days – if they or parents are opposed to OCPs – gives a luteal phase. If don’t get period by 35 days, they come in for 7 days and then get a period.
27
Q

Secondary amenorrhea: definition

A

The absence of periods for a length of time equivalent to a total of at least 3 of the previous cycle intervals OR 6 months of amenorrhea in a teen that was previously menstruating normally.

28
Q

Secondary amenorrhea: common causes

A

. pregnancy

  1. side effects of contraception

(OCP, DMPA)

  1. anovulation
  2. stress/ major life changes
  3. weight changes
  4. hyperprolactinemia/galactorrhea
  5. hypothyroidism
  6. polycystic ovary disease
  7. chronic illnesses – body & mental
  8. autoimmune disease (Addison’s)
  9. genetic diseases
  10. hypothalamic-pituitary disorders
  11. medications
29
Q

Evaluation in suspected secondary amenorrhea: History

A

History:

  • FMH: early or delayed menarche
  • PMH: chemo/radiation, galactorrhea, hirsutism, acne, menarche/menstrual hx
  • Meds: illicit or Rx drugs
  • ROS: temp intolerance, palpitationa, diarrhea, constipation, tremor, depression, skin changes; weight loss
  • social history: sexual activity, excessive exercise, poor nutrition, psychosocial stress, diets
  • developmental history
30
Q

Evaluation in secondary amenorrhea: PE

A
  • HT WT BMI: growth charts - turner or const delay
  • vital signs
  • Dysmorphic features (webbed neck, short stature, low hairline - turners)
  • Male pattern baldness, increased facial hair, acne: cushings, PCOS, etc
  • thyroid
  • visual fields – tumor – pushing on pituitary
  • skin – acne, AN, striae
  • breast
  • pelvic examination
31
Q

Lab tests in secondary amenorrhea

A
  • UCG* (tell them – need to check the box)
  • TSH*
  • prolactin*
  • testosterone total, % free, free* (PCOS – elevated free)
  • SHBG* Sex hormone binding globulin – binds free test. Will be normal or low in PCOS); insulin causes decrease in shbg. This is why ocps work in pcos – raise SHBGs.
  • early am cortisol
  • DHEAS
  • LH/FSH levels
  • Karyotype - Turner’s. Telltale sign is short. (can have a couple regular periods then drops off – early menopause
32
Q

management of secondary amenorrhea

A
  • Dependent upon etiology
  • Provera challenge 10 mg po QD x 7 days OR Provera 100 mg in oil IM
33
Q

athletic amenorrhea: definition

A

Amenorrhea secondary to participation in competitive athletics.

34
Q

Sports most often associated w/athletic amenorrhea (and why)

A
  • running, ballet, ice skating and gymnastics because of:
    • low weight for height
    • low percent body fat
    • high energy drain
    • low caloric intake
    • stress

usually solo sports w/a lot of personal stake

35
Q

Pathophysiology of athletic amenorrhea

A

remains unclear

36
Q

evaluation of suspected athletic amenorrhea

A
  • Athletes are as likely to have other causes of amenorrhea = SAME work-up as Secondary Amenorrhea
37
Q

Sequelae of athletic amenorrhea

A
  • disordered eating patterns
  • lowered bone mass*** think of w/all amenorrhea.
38
Q

mgmt of athletic amenorrhea

A
  1. decrease exercise / increase caloric intake
  2. estrogen replacement:

Premarin 0.625-1.25mg day 1-25 with Provera 10mg day 13-25

OR low dose OCP

  1. calcium replacement 1500 mg/day
  2. consider bone density studies – not great controls. Random bone density – don’t know where she was to begin with.
39
Q

Amenorrhea: what to do if elevated FSH and LH

A

Repeat in one month and if still elevated: primary ovarian insufficiency, natural menopause, order karyotype to r/o turners

40
Q

. As you evaluate an adolescent for a menstrual disorder- what questions would you ask about the menstrual cycle?

A

oWhen was your last menstrual period?

oAge of menarche

oHow often do you get your period?

oHow many days does your period last?

oHow heavy are your periods? How many pads/tampons do you use a day?

oAre your periods regular?

oDo you have painful periods?

oDo bleed between periods?

oIf you have symptoms, have they gotten worse over time? If your period is irregular now, is this new (had it been regular up till this point?)

oDo you take OCPs? Any missed pills?

41
Q

Describe dysmenorrhea for an adolescent and how your treatment plan fits with this condition

A

Your body makes hormones that cause your uterus to produce something called PGs. These prostaglandins cause pain in your uterus - you actually have PGs in other areas of your body and they also cause pain and cramps. Have you ever taken ibuprofen because a muscle hurt? The reason ibuprofen works is because it stops prostaglandins from causing pain. So just like you can take ibuprofen for other types of pain, it also helps with cramps.

If you have cramps all the time (or if you’re also sexually active), you could take OCPs. They work by stopping those hormones from making PGs in the first place. But they may not work for the first month or so, so it would be a good idea to take ibuprofen too.

42
Q

Describe DUB for an adolescent and how your treatment plan fits with this condition

A

Your period is irregular because your body is figuring how to coordinate all of the new hormones that are now around in your body. This happens in a lot of adolescents! To fix the problem, we give you birth control pills because the set level of hormone in these pills helps to even your cycle out. The pills will also keep the lining of your uterus thinner so you will lose less blood when you get your period. And since you’ve been bleeding more than usual, we’ll also give you some iron and vitamin C that helps you absorb the iron.

43
Q

Describe amenorrhea for an adolescent and how your treatment plan fits with this condition

A

Depends on the reason. if it’s athletic or eating do

Your body has actually shut off your reproductive system - because your body weight is so low that your body knows it could never support both you and a baby. This means that you’re not getting enough nutrition, you don’t have enough fat to keep your body healthy. That’s why we need to work on getting your body healthier - decrease exercise, increase calories, replace estrogen (e.g. low dose OCP), calcium.

44
Q

When might you order bone density studies?

A

any time there is amenorrhea. Low estrogen.

Eating d/o

45
Q

As you evaluate an adolescent athlete with amenorrhea- what questions will you ask about her about her training requirements?

A

Hours of exercise, type of exercise, how much food - any restrictions? Any days off? Weight requirements? Stress?

PC Ado (9 decks)

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